Authorization/Consent for Care/Service
The patient or representative signing below has been informed of the home care treatment and product options available to them and of the selection of providers from which the patient may choose. The patient further authorizes Hersource Inc. d/b/a HerSource Health (“Hersource ”) under the direction of the patient’s prescribing physician, to provide home medical equipment, supplies, and services. The patient has acknowledged that the Client/Patient Service Agreement has been explained and that the patient understands the information.
Assignment of Benefits/Authorization for Payment
All benefits and payments must be made directly to HerSource, Inc. for any HerSource furnished home medical equipment, products, and services. Hersource will seek such benefits and payments on the patient’s behalf. It is understood that, as a courtesy, HerSource will bill Medicaid or other federally funded sources and other payers and insurer(s) providing coverage, with a copy to HerSource. The patient is responsible for providing all necessary information and for making sure all certification and enrollment requirements are fulfilled. Any changes in insurance coverage must be reported to HerSource within 10 days of the change.
Release of Information
The patient or representative requests and authorizes HerSource, the prescribing physician, hospital, and any other holder of information relevant to service or equipment provided by HerSource, to release information upon request, to HerSource, any payer source, physician, or any other medical personnel or agency involved with service. The patient also authorizes Hersource to review medical history and payer information for the purpose of providing services, treatment, equipment or products.
Advanced Directives (Appendix B)
The patient understands their right to formulate and to issue Advance Directives to be followed should they become incapacitated
Financial Responsibility, Arrangements, and Health Insurance:
All payment and all sums that may become due for the services or products provided are due at the time services are rendered unless payment arrangements have been approved in advance by HerSource staff. These sums include, but are not limited to, all deductibles, co-payments, out-of-pocket requirements, and non-covered services. If for any reason and to any extent, HeSsource does not receive payment from the patient’s payer source because the patient is no longer eligible for coverage or because the service or product is not covered, the patient’s balance will be due in full, within 30 days of receipt of invoice. HerSource accepts cash, checks, & most major credit cards.
All patient owed charges not paid within 30 days of billing date shall be assessed late charges and are subject to legally allowable interest charges. In such an event, the patient will be liable for all charges, including collection costs and all attorneys’ fees, as applicable. Balances older than 90 days may be subject to additional collection fees and interest charges of 1.5% per month. We realize that temporary financial problems may affect timely payment to your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account.
Financial Responsibility for Non-Covered Items
By accepting these Terms and Conditions, the patient agrees that if the patient’s insurance does not cover all items and/or services ordered, even if the item and/or service is one that the patient or the healthcare provider has good reason to think is necessary, HerSource will not charge the insurance company and the patient will have financial responsibility for payment for the non-covered item(s) or service(s). The patient also agrees that HerSource has offered alternative covered items and/or services(if any and as applicable) and the cost of the non-covered item and/or service, and that the patient has then accepted financial responsibility for the non-covered item and/or service.
Due to Federal and State Pharmacy Regulations ancillary items prescribed for home health care cannot be re-dispensed and cannot be returned for credit. Sale items cannot be returned.
Consent for Contact
By signing and submitting this form, the patient or representative authorizes HerSource and its parent and sister companies, to contact them with recurring marketing and informational communications by phone or SMS, including through prerecorded or automated means, at the email address or number provided above. Calls may be generated using an automated technology and normal carrier charges may apply. Consent is not a condition of purchase.
Please be aware that most standard email is not a secure means of communication and your protected health information that may be contained in our emails to you will not be encrypted. This means that there is risk that your protected health information in the emails could be intercepted and read by, or disclosed to, unauthorized third parties. Use of alternative and more secure methods of communication with us, such as telephone, fax or the U.S. Postal Service are available to you. If you do not wish to accept the risks associated with non-secure unencrypted email communications from us containing your protected health information, please indicate that you do not wish to receive such emails from us by contacting us at 844-867-9890. If you agree to receive information from HerSource via email or text, you agree to accept the security and privacy risks of this type of communication.
By signing and submitting this form you also agree that if you consent to SMS notifications regarding your order, text alerts will be sent to the number you provide. You also understand that anyone with access to the mobile phone or carrier account associated with the number you have provided will be able to see this information.
Communication with Minors
We are committed to protecting the privacy of children. HerSource’s websites and ordering ability are not directed at users under the age of 18. If you are under the age of 18, you are not permitted to register with Hersource, submit personal information, or place orders.
Information for Medicare Patients
The products and/or services provided to the patient by HerSource are subject to the supplier standards contained in the federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g., honoring warranties and hours of operation). The full text of these standards can be obtained at http://ecfr.gpoaccess.gov. Upon request we will furnish you a written copy of the standards.
Hours of Service
HerSource is available from 9:00 AM – 5:00 PM EST Monday through Friday through our main telephone (888-732-3979). After hours and weekend calls will be returned within 24 hours. Should a life-threatening medical emergency arise, the patient or caregiver should contact their local emergency services number immediately for assistance (usually 911).
Patient Complaint/Grievance Process
In the event the patient should become dissatisfied with any portion of HerSource provided services or products a complaint may be lodged with HerSource without concern for reprisal, discrimination, or unreasonable interruption of service. The patient has the right to present questions or grievances to a member of HerSource’s staff and to receive a response in a reasonable period of time. For concerns regarding quality of care or other services, please contact HerSource’s office by phone or mail. Grievances can also be reported to the NC Division of Services intake unit, Medicare, or HerSource’s Medicare accreditation agency, ACHC. All contact information and our process for handling complaints can be found below.
The following procedure details the steps that HerSource will take when a client’s/patient’s complaint/grievance is received:
After receiving the concern, the HerSource Customer Service Supervisor will take the following steps:
- Contact the person making the concern within 5 days, if contact has not already been established.
- Determine what actions the caller feels should be initiated regarding the concern.
- Speak with involved employees and conduct additional training as appropriate.
- Attempt to resolve the concern to the client/patient’s satisfaction.
- Report status of activities to client/patient within 2 days following receipt of concern.
- Send complaint information to the Compliance Department so they can record it to the Compliant Log.
- If the complaint remains unresolved, the Compliance Department will have a department supervisor contact the patient within 5 working days.
- Within 14 days the company shall provide written notification to the patient of the results of the investigation.
Patient Satisfaction Surveys: Aeroflow Inc,, HerSource’s parent company, sends patient surveys via email appx 5-7 days after service has been rendered . Data collected/analyzed on a weekly basis. By signing below, you acknowledge that you have been informed of this patient satisfaction survey procedure.
What We Collect
We may collect the following information:
- Contact information including email address
- Demographic information such as postcode, preferences and interests
- Other information relevant to customer surveys and/or offers
What We Do With the Information We Gather
We require this information to understand your needs and provide you with a better service, and in particular for the following reasons:
- Internal record keeping.
- We may use the information to improve our products and services.
- We may periodically send promotional emails about new products, special offers or other information which we think you may find interesting using the email address which you have provided.
- We may also use your information to contact you for market research purposes. We may contact you by email, phone, fax or mail. We may use the information to customize the website according to your interests.
Uses and Disclosures
HerSource may use and disclose protected health information in the provisions, coordination, or management of your health care, including between health care providers, primarily in cases where we cannot adequately service your account due to insurance provider coverage.
We may use and disclose protected health information to obtain reimbursement for the services/products provided to you, including determinations of eligibility and coverage and other utilization review activities. This also includes contacting your insurer on your behalf to request that HerSource be allowed into your insurer’s network to facilitate you being able to obtain services under your in-network benefits.
To help with public health and safety issues (i.e product recalls).
To comply with the law – we will share your information if the state or federal laws require it. This does include the Department of Health and Human Services.
We can share your health information about you in response to a court or a subpoena.
We are committed to ensuring that your information is secure. In order to prevent unauthorized access or disclosure, we have put in place suitable physical, electronic and managerial procedures to safeguard and secure the information we collect online.
A cookie is a small file which asks permission to be placed on your computer’s hard drive. Once you agree, the file is added and the cookie helps analyze web traffic or lets you know when you visit a particular site. Cookies allow web applications to respond to you as an individual. The web application can tailor its operations to your needs, likes and dislikes by gathering and remembering information about your preferences.
We use traffic log cookies to identify which pages are being used. This helps us analyze data about web page traffic and improve our website in order to tailor it to customer needs. We only use this information for statistical analysis and then the data is removed from the system.
A cookie in no way gives us access to your computer or any information about you, other than the data you choose to share with us. You can choose to accept or decline cookies, but declining may prevent you from taking full advantage of the website.
Links to Other Websites
Our website may contain links to other websites of interest. However, once you have used these links to leave our site, we do not have any control over other websites. Therefore, we cannot be responsible for the protection and privacy of any information you provide other sites and such sites are not governed by this privacy statement. Exercise caution and look at the privacy statement applicable to the website in question.
Controlling Your Personal Information
You may choose to restrict the collection or use of your personal information in the following ways:
- Whenever you fill out our Qualify Through Insurance form, check the box that indicates you do not want the information to be used for direct marketing purposes.
- If you have previously agreed to us using your personal information for direct marketing purposes, you may change your mind at any time by emailing us at firstname.lastname@example.org.
We will not sell, distribute or lease your personal information to third parties unless we have your permission or are required by law to do so. We may use your personal information to send you promotional information about third parties that we think may be of interest to you.
You may request details of personal information which we hold about you under the Data Protection Act 1998. A small fee will be payable. If you would like a copy of the information held on you please write to HerSource at 65 Beale Rd, Arden, NC 28704.
If you believe that any information we are holding on you is incorrect or incomplete, please write to or email us as soon as possible, at the above address. We will promptly correct any information found to be incorrect.
What is an Advance Directive? An advance directive is a set of directions you give about the medical and mental health care you want if you ever lose the ability to make decisions for yourself. There are two ways for you to make a formal advance directive. These include: Living Wills and Healthcare Powers of Attorney. Forms & additional information may be obtained from the Secretary of State website.
Do I have to have an Advance Directive and what happens if I don’t? Making an advance directive is your choice. If you become unable to make your own decisions, and you have no advance directive, your physician or mental health care provider will consult with someone close to you about your care. Discussing your wishes with your family and friends now will help ensure that you get the level of treatment you want when you can no longer tell your health providers what you want.
What is a Living Will? A Living Will is a legal document that tells others that you want to die a natural death if you: become incurably sick with an irreversible condition that will result in your death within a short period of time; are unconscious and your physician determines that it is highly unlikely you will regain consciousness; or have advanced dementia or a similar condition which results In a substantial cognitive loss and it is highly unlikely the condition can be reversed. You can direct your physician not to use certain life-prolonging treatments such as a breathing machine (“respirator” or “ventilator”), or to stop giving you food and water through a tube (“artificial nutrition or hydration” through feeding tubes and IVs). The document goes into effect only when your physician and one other physician determine that you meet one of the conditions specified in the Living Will. You can cancel anytime by communicating your intent to cancel it in any way.
What is a Healthcare Power of Attorney? A Healthcare Power of Attorney is a legal document in which you can name a person(s) as your health care agent(s) to make medical and mental health decisions for you if you become unable to decide for yourself. You can say which treatments you would want and not want. You should choose an adult you trust to be your health care agent. Discuss your wishes with that person(s) before you put them in writing. The document will go into effect when a physician states in writing that you are not able to make or to communicate your health care choices. You can cancel or change while you are able to make and communicate your decisions.
How do I make an Advance Directive? There are several rules to protect you and ensure your wishes are clear to the physician who may be asked to carry them out. An advanced directive must be: (1) written; (2) signed by you while you are still able to make and communicate health care decisions; (3) witnessed by two qualified adults; and (4) notarized. A qualified witness is a competent adult who sees you sign, is not a relative, and will not inherit anything from you upon your death. The witness cannot be your physician, a licensed employee of your physician or any paid employee of a healthcare facility where you live or that is treating you.
Who should I talk to about an Advance Directive? You should talk to those closest to you about an advance directive and your feelings about the health care you would like to receive. Your physician or health care provider can answer medical questions. A lawyer can answer questions about the law. Give copies to your family, your physician or mental health providers, your health care agent(s), and any family members or close friends who might be asked about your care should you become unable to make decisions. Please furnish HerSource with a copy of your advance directives.
It is the policy of HerSource to conform to the acceptable standards of infection control pertaining to equipment and home health services issued by the Centers for Disease Control (CDC) and the Occupational Safety and Health Administration (OSHA), in order to ensure the safety of clients/patients and employees, and also to ensure quality client/patient service
How infections occur and are spread: An infection occurs when germs enter the body, increase in number, and cause a reaction of the body.
Three things are necessary for an infection to occur:
- Source: Places where infectious agents (germs) live (e.g., sinks, surfaces, human skin)
- Susceptible Person with a way for germs to enter the body
- Transmission: a way germs are moved to the susceptible person
There are a few general ways that germs travel in healthcare settings:
- Through contact (i.e., touching)
- Sprays and splashes (when an infected person coughs or sneezes)
- Inhalation (when germs are aerosolized in tiny particle)
- Sharp injuries (i.e., when someone is accidentally stuck with a used needle or sharp instrument).
How to prevent infection:
- Wash your hands often
- Get vaccinated
- Get vaccinated and use antibiotics sensibly
- Stay at home if you have signs and symptoms of an infection.
- Cover your mouth and nose
- Disinfect the ‘hot zones’ in your residence – the kitchen and bathroom
- Don’t share personal items
- Make sure health care providers clean their hands or wear gloves
- Clean equipment and supplies regularly
- Replace equipment on a regular schedule. Contact Hersource (888-732-3979) when your supplies are to be thrown out.
Symptoms of Hepatitis infection: Extreme fatigue, mild fever, headache, loss of appetite, nausea, and vomiting. Symptoms of Tuberculosis (TB) infection: fatigue, anorexia, productive cough, coughing up blood, weight loss, loss of appetite, lethargy, weakness, night sweats, chills, flu-like symptoms and fever. Some people with TB may show no symptoms. NOTIFY YOUR HEALTHCARE PROVIDER IF YOU FEEL YOU HAVE BECOME INFECTED.
How to Make Your Home Safe for Medical Care
At HerSource, we want to make sure that your home medical treatment is done conveniently and safely. In some other areas of our business, we have clients/patients who are limited in strength, or unsteady on their feet. Some are wheelchair or bed-bound. These pages are written to give all our clients/patients some easy and helpful tips on how to make the home safe for home care. Discuss these plans with your family members.
Fire Safety and Prevention
- Smoke detectors should be installed in your home: make sure you check the batteries at least once a year. If appropriate, you may consider carbon monoxide detectors as well. Ask your local fire department if you should have one in your home.
- Have a fire extinguisher in your home, and have it tested regularly to make sure it is still charged in working order. And, have a plan for escape in the event of a fire.
- If you are using electrical medical equipment, make sure to review the instruction sheets for that equipment. Read the section on electrical safety.
- Make sure that all medical equipment is plugged into a properly grounded electrical outlet.
- If you have to use a three-prong adapter, make sure it is properly installed by attaching the ground wire to the plug outlet screw.
- Use only good quality outlet “extenders” or “power strips” with internal circuit breakers. Don’t use cheap extension cords.
Safety in the Bathroom
- Use non-slip rugs on the floor to prevent slipping.
- Install a grab-bar on the shower wall and non-slip footing strips in the tub or shower.
- Ask your medical equipment provider about a shower bench you can sit on in the shower.
- If you have difficulty sitting and getting up, ask about a raised toilet seat with arm supports to make it easier to get on and off the commode.
- If you have problems sensing hot and cold, you should consider lowering the temperature setting of your water heater so you don’t accidentally scald yourself without realizing it.
Safety in the Bedroom
- It’s important to arrange a safe, well-planned and comfortable bedroom since a lot of your recuperation and home therapy may occur there.
- Ask your home medical provider about a hospital bed. These beds raise and lower so you can sit up, recline, and adjust your knees. A variety of tables and supports are also available so you can eat, exercise and read in bed.
- Bed rails may be a good idea, especially if you have a tendency to roll in bed at night.
- If you have difficulty walking, inquire about a bedside commode so you don’t have to walk to that bathroom to use the toilet.
- Make sure you can easily reach the light switches, and other important things you might need throughout the day or night.
- Install night-lights to help you find your way in the dark at night.
- If you are using an IV pole for your IV or enteral therapy, make sure that all furniture, loose carpets, and electrical cords are out of the way so you do not trip and fall while walking with the pole.
Every client/patient receiving care or services in the home should think about what they would do in the event of an emergency. Our goal is to help you plan your actions in case there is a natural disaster where you live and to try to provide you with the best, most consistent service we can during an emergency.
Know what to expect: If you have recently moved to this area, take the time to find out what types of natural emergencies have occurred in the past, and what types might be expected. Find out what, if any, times of year these emergencies are most prevalent. Find out when you should evacuate, and when you shouldn’t. Your local Red Cross, local law enforcement agencies, local news and radio stations provide excellent information and tips for planning.
Know where to go: One of the most important pieces of information you should know is the location of the closest emergency shelter. These shelters are open to the public during voluntary and mandatory evacuation times. They are usually the safest place for you to go, other than a friend or relative’s home in an unaffected area.
Know what to take with you: Some shelters may have restrictions on what items you can bring with you. Not all shelters have adequate storage for medications that need refrigeration. We recommend that you call ahead to find out if you can bring your medications and medical supplies. In addition, let them know if you will be using medical equipment that requires an electrical outlet. During our planning for a natural emergency, we will contact you and deliver, if possible, at least one weeks’ worth of medication and supplies. Bring all your medications and supplies with you to the shelter.
Reaching us during an emergency: In the case of an emergency, please call our main phone number (888-732-3979). If the office is closed due to an emergency, our on-call services are always available. If you have no way to call our number, you can try to reach us by having someone you know call us from his or her cellular phone. Should a life-threatening medical emergency arise it is suggested the patient or caregiver contact their local emergency services number for assistance (usually 911).
Client/Patient Bill of Rights & Responsibilities
Client/Patient has the right to:
- Receive reasonable coordination and continuity of services from the referring agency for home medical equipment services
- Receive a timely response from HerSource when services/care are needed or requested
- Be fully informed in advance about service/care to be provided, including the disciplines that furnish care and the frequency of visits, as well as any modifications to the Plan of Care
- Participate in the development and periodic revision of the Plan of Service or the Plan of Care
- Informed consent and refusal of services, care or treatment after the consequences of refusing services, care or treatment are fully presented
- Be informed in advance of the charges, including payment for service or care expected from third parties and any charges for which the client/patient will be responsible
- Have one’s property and person treated with respect, consideration, and recognition of client/patient dignity and individuality
- Be able to identify visiting staff members through proper identification
- Voice grievances/complaints regarding treatment of care or lack of respect of property, or recommend changes in policy, staff or service/care without restraint, interference, coercion, discrimination or reprisal
- Have grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect of property investigated
- Choose a health care provider and have access to information regarding provider’s work history and training
- Confidentiality and privacy of all information contained in the client/patient record and of Protected Health Information
- Receive appropriate service/care without discrimination in accordance with physician orders
- Be informed of any financial benefits when referred to an organization
- Be informed in advance of care/service being provided and their financial responsibility
- Be fully informed of one’s responsibilities and HerSource’s policies regarding patient responsibilities
- Be informed of client/patient rights under state law to formulate advance care directives
- Be informed of anticipated outcomes of service or care and of any barriers in outcome achievement
- Be informed of HerSource’s on-call service.
- Be informed of HerSource’s patient satisfaction survey process.
- Be informed of supervisory accessibility and availability.
- Fair treatment, regardless of race, ethnicity, creed, religious belief, sexual orientation, gender, age, health status, or source of payment for care.
- Be advised on HerSource’s policies and procedures regarding the disclosure of clinical records, clinical guidelines, and management of care
- Be advised of HerSource’s procedures for discharge.
- Report fraud, waste, or abuse
- Be notified within 10 days if HerSource’s license is revoked, suspended, canceled, annulled, withdrawn, recalled, or amended.
- Know of their rights and responsibilities in the treatment process (and the laws that relate to them), and to make recommendations regarding the organization’s rights and responsibilities policy.
- Be informed about advocacy and community groups and prevention services.
- Access care easily and in a timely fashion.
- Candid discussion about all their treatment choices, regardless of cost or coverage by their benefit plan.
- The delivery of services in a culturally competent manner.
- Receive information about the scope of services that the organization will provide and specific limitations on those services.
- Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of an unknown source, and misappropriation of client/patient property.
Client/Patient has the responsibility to:
- Client agrees that rental equipment will be used with reasonable care, not altered or modified, and returned in good condition (normal wear and tear excepted).
- Client agrees to promptly report to HerSource any malfunctions or defects in rental equipment so that repair/ replacement can be arranged.
- Client agrees to provide HerSource access to all rental equipment for repair/replacement, maintenance, and/or pick-up of the equipment.
- Client agrees to use the equipment for the purposes so indicated and in compliance with the physician’s prescription.
- Client agrees to keep the equipment in their possession and at the address, to which it was delivered unless otherwise authorized by HerSource
- Client agrees to notify HerSource of any hospitalization, change in customer insurance, address, telephone number, physician, or when the medical need for the rental equipment no longer exists.
- Client agrees to request payment of authorized Medicare, Medicaid, or other private insurance benefits are paid directly to HerSource for any services furnished by HerSource.
- Client agrees to accept all financial responsibility for home medical equipment furnished by HerSource
- Client agrees to pay for the replacement cost of any equipment damaged, destroyed, or lost due to misuse, abuse or neglect.
- Client agrees not to modify the rental equipment without the prior consent of HerSource.
- Client agrees that any authorized modification shall belong to the titleholder of the equipment unless equipment is purchased and paid for in full.
- Client agrees that title to the rental equipment and all parts shall remain with HerSource at all times unless equipment is purchased and paid for in full.
- Client agrees that HerSource shall not insure or be responsible to the client for any personal injury or property damage related to any equipment; including that caused by use or improper functioning of the equipment; the act or omission of any other third party, or by any criminal act or activity, war, riot, insurrection, fire or act of God
- Client understands that HerSource retains the right to refuse delivery of service to any client at any time.
- Client agrees that any legal fees resulting from a disagreement between the parties shall be borne by the unsuccessful party in any legal action taken.
- Patients/Clients have the responsibility to give providers the information they need, in order to provide the best possible care and to ask questions about their care.
- Clients have the responsibility to treat those giving them care with dignity and respect and not to take actions that could harm others.
- Patients/Clients have the responsibility to understand and help develop and follow the agreed-upon treatment plans for their care, including the agreed-upon medication plan and to let the provider know when the treatment plan no longer works for them.
- Patients/Clients have the responsibility to keep their appointments. Patients should call their providers as soon as possible if they need to cancel visits.
- Patients/Clients have the responsibility to let their provider know about any changes to their contact information (name, address, phone, etc.) and insurance coverage.
- Patients/Clients have the responsibility to tell their provider about medication changes, including medications given to them by others.
- Patients/Clients have the responsibility to let their provider know about problems with paying fees.